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					Warning Signs for Possible
 Behavioral Problems in
   Infants & Toddlers

  Guidelines for Mental Health

          Richard J. Pines, D.O.
Saint Alphonsus Behavioral Health Services
 Risk Factors Common to Many
       Mental Disorders I

The interaction of risk and protective factors is
very complex and varies from one individual to
    Risk Factors Common to Many Mental
                 Disorders II
                   Biological Factors

• Genetic vulnerability due to family history of mental
• Difficult inherent temperament.
• Prematurity/Low birth weight.
• Chronic physical illness.
• Neurological deficits.
• Uneven intelligence.
• Early language delays/Learning disabilities.
• Male gender.
• Substance abuse.
Nine Inherited Personality Traits

1.   Activity Level
2.   Regularity
3.   Approach or Withdrawal
4.   Adaptability
5.   Sensory Threshold
6.   Mood
7.   Intensity
8.   Distractibility
9.   Persistence
  Risk Factors Common to Many Mental
              Disorders III
               Psychological Factors

• Experiencing severe marital discord.
• Physical or sexual abuse.
• Poor family relations and dysfunctional
• Parental mental disorder.
• Experiencing change in circumstances, support
  status, health, or self-image.
• Experiencing severely traumatic life experiences.
Risk Factors Common to Many Mental
             Disorders IV
             Socioeconomic Factors

• Poverty

• Overcrowding or large family size

• Poor school environment
Risk Factors Common to Many Mental
             Disorders V
                  Protective Factors I

• Genetic inheritance with no family history of mental
• Good health and health care, including prenatal.
• Positive temperament/Sense of humor.
• Above average intelligence.
• Social competence/Ability to get along with others.
• Smaller family size.
• Close relationship with a parent who is responsive and
• Supportive parents.
Risk Factors Common to Many Mental
             Disorders VI
                  Protective Factors II

• Good sibling relationships.
• Adequate rule setting by parents/Constructive discipline.
• Good relationships with peers and adults outside the
• Opportunities to function in a variety of settings.
• Sense of being in control of one’s life.
• High sense of personal competence and self-esteem.
• Good schools.
• Avoidance of substance use/abuse.
A Child’s Stages of Development
            Ages 0-1

 Developmental Goal:
   To Develop Autonomy.
    •   Independence
    •   Language
    •   Ability to explore
    •   Self Control
A Child’s Stages of Development
            Ages 0-1

 Potential Problem Areas:
 •   Parental immaturity.
 •   Chaotic home environment.
 •   Developmentally delayed baby.
 •   Baby with difficult temperament.
 •   Failure to develop basic trust.
A Child’s Stages of Development
            Ages 0-1
 “Normal” Difficult Behavior:
 • Child cries in rage until needs are met.
 Cries For Help:
 •   Excessive crying.
 •   Sleep disturbance.
 •   Feeding disorders.
 •   Extreme stranger anxiety.
 •   Won’t cuddle.
 •   No eye contact.
 •   No smiling.
 • Muscular rigidity.
A Child’s Stages of Development
            Ages 1-3

 Developmental Goal:
   To develop basic trust.
    • Trust that adults will meet basic needs.
    • Trust own body as muscular coordination develops.
A Child’s Stages of Development
            Ages 1-3

 Potential Problem Areas:
 •   Previous developmental goal not met.
 •   Stress on family system.
 •   Changes in environment.
 •   Child is unable to explore his or her environment due to a
     physical or mental handicap or too rigid restraint.
 •   Stressful, chaotic, dangerous, hostile, or abusive environment.
 •   Child is emotionally neglected and not spoken to.
 •   Child has a neurological impairment preventing his learning
     from environment & developing self control.
 •   Child is not taught to respect limits.
A Child’s Stages of Development
            Ages 1-3

 “Normal” Difficult Behavior:
 • Constant exploration involving running, climbing, and
   getting into things.
 • Negativity (Every response is, “No!”)
 • Clinging to pacifier and/or blanket.
 • Thumb sucking.
 • Hitting or biting to get attention.
 • Curiosity about his own body parts and sexual
   differences; masturbation.
 • Regressing to infantile behavior occasionally.
A Child’s Stages of Development
            Ages 1-3

 Cries for Help:
 • Significant sleeping problems, (e.g., night terrors.)
 • Eating problems.
 • Failure of language development.
 • Continual thumb sucking.
 • Inability to separate from mother without extreme
 • Severe temper tantrums.
 • Inability to toilet train.
    Growth, Weight, and Eating I

• The child is not gaining weight or is
  stationary (e.g., failure to thrive or growth

• The child is not growing in stature (growth
   Growth, Weight, and Eating II

• The child shows no maturation in ability to
  feed, (e.g., eats only liquid food in second
  year of life.)

• The child looks malnourished, too thin.
  May have no interest in food.
   Growth, Weight, and Eating III

• The caretaker notes the child is not
  interested in food, has no appetite, or it is
  hard to feed him or her.

• The child is too picky, a finicky eater, or
  has excessive selectivity. Food refusal or
  frequent vomiting.
       Irritability and Crying I

• The child is “colicky” after 3 months of life.

• The child cries more than 3 hours in a 24 hour

• The child is fussy most of the time.

• The child is constantly irritable and restless.
      Irritability and Crying II

• It is hard to soothe the child.

• Once the child starts crying he or she is hard
  to calm.

• The child has very little patience.
           Relatedness and

• The child appears unfocused.

• The child is unresponsive/not connected
  with those around him or her or is not
  responsive to them.

• No eye contact. No smile.
          Anxiety or Trauma

• History of major traumatic event, (e.g.,
  domestic violence.)

• The child appears hypervigilant, anxious,
  excessively worried, or “frozen” at times.

• The child is shaky, tremulous, or easily

• The child appears somber and worried.

• The child appears sad and unenergetic.

• The child exhibits very little joy.
• The child wakes up many times during the night
  after 6 months of age.

• The child has much difficulty settling at bed time.

• Parasomnias, night terrors, or somnambulism may
  be exhibited by the child.
• No cooing or attempts to mimic words or phrases.

• After one year, no pointing and/or appropriate use
  of body language.

• Difficulty in scanning faces.

• No words with communicational intent.
         Child: Hypersensitive I

• The child appears hypertonic, rigid, tense.

• The child is too sensitive to noises, being touched,
  or does not like being held.
         Child: Hypersensitive II

• The child is sensitive or uncomfortable in certain
  body positions.

• The child becomes disorganized during feedings
  and many other activities.

• The child is unfocused or constantly restless.
           Maternal Depression

• Mother looks sad and/or exceedingly tired.

• Mother feels no joy regarding the child.

• Mother states feeling blue, exhausted all the time,
  or overwhelmed.

• Little partner support for mother.
       Parent-Child Relationship

• Negative statements about the child.

• Malignant attributions of intent toward the child.

• Handles the child in a rough way.

• Loses patience with the child, talks angrily, or
  without empathy.
       Parent-Child Relationship
                 Underinvolved I

• Poor hygiene in the child.

• No pride in dressing or grooming the child.

• Comes to appointment without any toy or object to
  entertain the child.

• Comes to appointment without diaper, bottle, or
       Parent-Child Relationship
                 Underinvolved II

• Consistently disregards messages from the child
  (e.g., crying, vocalizations, signals of distress.)

• Is not attentive toward the child. Does not notice

• Forgets the child’s feeding, change of diaper, etc.
       Parent-Child Relationship

• Parent focused mostly on own needs.

• Child has to follow parent’s schedule, perceptions,
  and needs.

• Little empathy toward child’s challenges or needs.
       Parent-Child Relationship
                      Poor Fit

• Parent consistently misreads child.

• Parent talks loudly and is too animated with a very
  sensitive child.

• Parent is too quiet and soft with an undersensitive

• Little intimacy and mutual joy.
         High Stress in Caretaking

• Violence in home or environment.

• Few boundaries in home.

• Drug use in the home (cocaine, alcohol, etc.)

• Problems with housing and/or access to health care, mental
  disorder in family.

• Parent has difficulty in his or her job.
Parental Mental Health I

Increased Aggression in Children:
• Maternal alcohol abuse.
• High frequency of maternal depressive episodes.

Increased Incidence of Conduct
Disorder in Children:
• Paternal alcohol abuse.
• Low socio-economic status.
    Parental Mental Health II

Children of Alcoholics:
•   Increased truancy.
•   Increased contacts with police.
•   Increased substance abuse.
•   Increased school drop-outs.
 Parental Mental Health III
Protective Factors in Parental Mental
• Having good interpersonal relationships outside of
• Having a strong sense of self.
• Having a clear understanding of parent’s mental illness.
• Children caring for younger siblings often develop
  enhanced problem-solving skills and greater
     Community Nurturing of
       “At-Risk” Youth I

Children Need:
• A healthy biological inheritance.

Communities Can:
• Educate potential parents about the importance of both
  parents being in good health at the time of conception.
     Community Nurturing of
       “At-Risk” Youth II

Communities Can (cont.):
• Ensure accessible and affordable prenatal care.

• Educate potential parents that genetic inheritance
   causes a vulnerability to many physical and
   mental/neurological disorders.

• Ensure access to adequate medical care during the birth
      Community Nurturing of
        “At-Risk” Youth III

Children Need:
Capable caregivers to provide for physical & emotional

Communities Can:
Provide education for parents and potential parents
regarding children’s developmental needs and stages.
         Community Nurturing of
           “At-Risk” Youth IV

  Communities Can (cont.):
• Identify parents at high risk for abusive behavior (ideally
  before the birth).

• Provide education, empathy, and support for high risk
  parents before an episode of abuse occurs.

• Recognize the importance of a child’s having a consistent,
  nurturing caretaker with whom he or she can form a deep,
  long-term, secure attachment.
         Community Nurturing of
           “At-Risk” Youth V

  Children Need:
• Understanding

  Communities Can:
• Increase community understanding of mental/neurological

• Identify children with mental/neurological disorders.
         Community Nurturing of
           “At-Risk” Youth VI

  Children Need:
• Community role models and mentors
  Communities Can:
• Interact with youth while modeling positive values and
• Volunteer time to serve as mentors one-on-one with
  specific youth.
• Look out for children in the community and accept a
  nurturing role in caring for them.
• Avoid applying quick labels to difficult youth.

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